Every finding on record at Harbor Hospice of Corsicana LP

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not conduct a hazard vulnerability analysis for the current location. For example the HVA included in the plan was for the previous location in Dallas, not the current location in Corsicana many miles away from Dallas. This was confirmed and discussed with the DPCS present.

Observed in Record Review. In 5 of 14 patient records reviewed, it was noted that the record was incomplete. For example in record RRBR#1 the record did not have any IDG documentation. Record RRNHV#2 the second IDG documentation was incomplete with No current plan of care documented however in the EHR there was a plan of care documented in another area. Record RRNHV#4 there was no SN frequency order. Record RRNHV#6 IDG #1 and RRNHV#7 IDG#2 documentation stated No goals. and No interventions. however there were goals and interventions documented in another part of the record. This was confirmed and discussed with the DPCS present.

Observed in Record Review. In 8 of 10 patient records reviewed, it was noted that the plan of care was not individualized. For example in record RRHV#1, 11 of 11 goals time frames were identical/the next recertification date. These goals included areas such as the appropriate use of assistive devices, urinary elimination, pain management and improved safety awareness which identical time frames would be inappropriate. Also the record included the incomplete goal Caregiver will be able to demonstrate improved safety awareness as evidenced by:_____. In record RRHV#3, 12 of 12 goals time frames were identical/the next recertification date. The record included goals: Pt/CS will perform ADL's with optimal ability and Promote skin integrity. In record RRNHV#5 all goal time frames were dated with dates 4-6 months prior to the patient's admission to the hospice. Record RRNHV#1,2,3,4 and 7 had similar POC goal issues.This was confirmed and discussed with the Administrator/DPCS present.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that there was no a statement of the scope and frequency of services necessary to meet the patient and family needs. For example, Record RRNHV#2 the second IDG documentation was incomplete with no frequencies. Record RRNHV#4 there was no SN frequency order. Record RRNHV#6 IDG #1 and RRNHV#7 IDG#2 there were no frequencies. . This was confirmed and discussed with the DPCS present.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that the IDG had not reviewed and revised the POC. Record RRNHV#2 the second IDG documentation was incomplete with no goals and interventions it stated No current plan of care. Record RRNHV#6 IDG #1 and RRNHV#7 IDG#2 there were no goals and interventions they stated No goals. and No interventions. This was confirmed and discussed with the DPCS present.

Observed in Record Review. In 2 of 6 patient records reviewed, it was noted that the hospice aide supervision not completed every 14 days. For example in record RRHV#3 there was 21 days from the start of aide services to the first documentation of supervision of aide services. Record RRNHV#3 there was 20 days between documentation of supervisory visits. This was confirmed and discussed with the Administrator/DPCS present.

Observed in Tracer Activities. During review of the volunteer program and discussion with the Volunteer Coordinator and DPCS it was noted that the hospice was not able to demonstrate viable and ongoing efforts to recruit and retain volunteers. For example, the organization documented that there were no volunteers the year 2025 and January to current 2026. The Volunteer Coordinator stated that she was new to the organization February 2026 and discussed plans for recruitment, but was unable to demonstrate that recruitment had taken place.

Observed in Tracer Activities. During review of the Volunteer Program and discussion with the Volunteer Coordinator and DPCS it was noted that there was no cost savings documented. During discussion there have been no volunteers for the year 2025 and January to current 2026, so unable to document cost savings. This was confirmed and discussed with Volunteer Coordinator and DPCS.

Observed in Tracer Activities. During the Volunteer Program review and the Data session it was noted that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example the year 2025 and January to April 2026 volunteers provided 0% of the total patient care hours. This was confirmed and discussed with the DPCS present.

Observed in Tracer Activities. : There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.78 volunteer services.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge patients it was noted that the record was inaccurate or contains errors. For example in record RRDC#1 the discharge summary stated the patient had revoked services, there was no revocation document in the record. The last IDG documented stated the patient had transferred to another hospice, there was no transfer document and no transfer order. This was confirmed and discussed with the DPCS present.

Observed in Patient Home. In 1 of 1 home visits conducted, that included oxygen therapy it was noted that staff did not provide education on the safe storage of oxygen cylinders in the home. For example during visit RRHV#3 there were 3 oxygen tanks free standing in the living room and 1 additional that was on a cart. The visit was attended by both the aide and the RN and neither of these staff members educated on proper storage of oxygen tanks. This was discussed with the DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, for active patients HOSHV#1/RR#1 and HOSHV#3/RR#3, it was noted by the nurse surveyor that the goals were not measurable. For example, “Patient maintains highest level of possible mobility” or “Patient/family will express satisfactory control of symptoms”. Findings were verified by the Administrator/Director of Nursing.

Observed in Record Review. In 2 of 3 patient records reviewed, for active patients, it was noted by the nurse surveyor that the scope and frequency included unspecified or unrealistic PRN orders. For HOSHV#1/RR#1 the MSW frequency was SW 1m 3m 2 PRN as needed and the Chaplain frequency was 6 PRN; Chaplain will visit patient as needed. For HOSHV#3/RR#3, the skilled nurse frequency was 1wk9, 32 PRN symptom management & change in condition. Findings were verified by the Administrator/Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy” and “Bag Technique Policy”. For example, during HOSHV#1/RR#1 the chaplain did not hand sanitize at any time during the visit with the patient in the nursing facility. She entered the building, stopped at the nurse’s station, and put her hands on the counter, entered the patient’s room, touched the patient’s phone and overbed table all without hand sanitizing. During HOSHV#2/RR#2 with a skilled nurse, she donned and doffed gloves without hand sanitizing on several occasions. She missed several opportunities to change gloves when going from patient to items around the patient and back to the patient. Additionally, throughout the visit, she went in and out of her nursing bag without hand sanitizing. Findings were verified by the Administrator/Director of Nursing who was present during the visit. Observed in Patient Home. In 1 of 3 home visits conducted, t was observed by the nurse surveyor that the field staff did not clean their equipment per agency policy “Bag Technique Policy”. For example, during HOSHV#2/RR#2- after taking the patient’s temperature and auscultating his lungs and abdomen with her stethoscope, the nurse dropped both pieces of equipment into her nurse’s bag without cleaning as instructed in agency policy. Findings were verified by the Administrator/Director of Nursing who was present during the visit.

Observed in Tracer Activities. In 3 of 3 patient records reviewed, The surveyor observed that the chaplain and social worker failed to complete their initial assessments within five days after the election of hospice. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor found that the social work left the organization in June of 2022 and had not been replaced until November of 2022 the team had been working without a social worker for 5 months. Organization leaders stated previous administrator had not informed the organization of missing social worker and as soon as they were aware they replaced social. The surveyor verified this issue ended November 22 with observed social worker assessments and notes from November 2022 - survey date.

Observed in Patient Home. The surveyor observed that the hospice aide failed to perform hand hygiene at times required by standard precautions and organizational policies as evidenced by: The hospice aide did not change gloves or clean hands between cleaning peri/anal areas of patient and cleaning upper back, neck, and legs. Further the surveyor noted that the hospice aide had not changed water that she rinsed both cleaning towels in. This was discussed with the organization.

Observed in Tracer Activities. The surveyor observed on the one bereavement record for the year 2022 that a plan had not been developed . The surveyor found no bereavement notes on the record at all. Leadership stated that the former administrator had not informed corporate of loss of chaplain/ bereavement coordinator and so there had been nobody completing bereavement. This office had small census and only one death noted by surveyor.